An 18-year-old woman presents with frequent
headaches, each lasting for several days. She has to take time off
from school. She describes them as throbbing, localized to the temporal region.
They are associated with nausea and vomiting, sensitivity to sound
and light. A recent MRI was normal. A diagnostic lumbar
puncture done was normal. The most probable cause of her headaches
postdural puncture headache
The management of headaches is based on the correct
diagnosis. Postdural puncture headaches develop after a dural puncture
such as a spinal tap. The pain is usually frontal and occipital. It
becomes worse in the upright position and is relieved significantly
with lying supine. Some patients develop sixth cranial nerve palsy
because of the long intracranial course of the sixth cranial nerve.
The differentiation between tension-type headache (TTH) and migraine
without aura is much more difficult. Very often both headaches coexist.
TTHs are tightening or pressing in character. They are mild to moderate
in intensity and are bilateral. TTH is seldom associated with nausea and
in most patients TTH is not greatly exacerbated by physical activity.
Giant-cell (temporal) arteritis affects the extracranial vessels
of the head and arms. There is tenderness over the scalp. The temporal
or occipital arteries are enlarged and tender. They may have visual
symptoms including amaurosis fugax, diplopia, and blindness. Most
patients also have symptoms of intermittent claudication with chewing.
A temporal artery biopsy is diagnostic.
According to the International Headache Society, headaches are
classified into primary and secondary headache disorders. The primary
headache disorders consist of:
- Migraine with aura
- Migraine without aura
- Tension-type headache—chronic and episodic
- Cluster headache—chronic and episodic
Primary headaches, such as migraine with or without aura, tension-type,
and cluster headache constitute about 90% of all headaches.
Migraine as defined by the International Headache Society is idiopathic,
recurring headache disorder manifesting in attacks lasting 4 to